June 2022

In This Issue: HSR&D Research on Community Care
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Utilization and Health Outcomes for Veterans with Expanded Access to Healthcare

Feature Article

Takeaway: By working with operational partners, investigators will identify opportunities and barriers to implementing access measures and metrics derived from their findings. This information will be key to setting policy related to VA’s evolution into a provider and payer of healthcare for Veterans, while ensuring that they receive high-quality care in both VA and non-VA settings.

Improving access to high-quality care is a top priority for VA. However, access is difficult to measure, especially in the ever-changing U.S. healthcare landscape. VA currently focuses on perceived satisfaction measured from survey questions or wait times measured with administrative data. However, wait time measures are not only challenging to interpret, but are rarely available from community providers, hindering any VA to non-VA comparisons. VA leaders tasked with implementing the MISSION Act desire better evidence-based access measures so they can evaluate its impact. Without new metrics that track gaps or improvements in access, VA is likely to invest in the wrong initiatives, fueling critics who will argue that privatization will fix the programs.

This ongoing study (July 2020 – June 2023) is working to develop new measures of access that will provide causal information on gaps in VA services, while also showing the potential impact that expanded access would have on Veterans’ health and care. Specific aims include:

• Ascertaining the causal impact of Medicare eligibility on Veterans’ health and use of care – and identifying procedures and diagnosis groups that are most affected.
• Determining the causal impact of VA Community Care (VACC) on Veterans’ health and use of care – and identifying the procedures and diagnoses most affected.
• Identifying subgroup analyses that would give crucial information to VA leaders.

This study leverages natural experiments in the form of arbitrary administrative rules that enable Veterans to access care outside VA in the forms of Medicare and  (VACC).

Methods

This study applies novel econometric techniques to take advantage of natural experiments and find the causal effects of increasing access. Investigators will gather a near complete census of VA and non-VA records for all recent VA users, allowing for precise claims-based measures of utilization, health, and mortality. This approach leverages the sharp change in Medicare eligibility that occurs at age 65 to find the effect of Medicare on healthcare use and Veterans’ health. Investigators will take a combined approach of working with their operational partner (VA’s Office of Veterans Access to Care) and applying machine learning techniques for heterogenous treatment effects to identify and examine metrics and measures that can be used for policy formation.

Findings

Thus far, results from this study have been published in JAMA Network Open and earned the authors HSR&D’s Best Paper Award (2021). Utilizing causal inference methods, they determined that the VA Choice Act – and expanded access to providers – caused a significant increase in outpatient (+3%), laboratory (+3%), prescription (+1%), and psychotherapy (+8%) visits without changes to inpatient use or mortality). Increased outpatient use was most concentrated among Veterans with more service-connected disabilities – and among younger Veterans without service-connected disabilities.

Anticipated Impact

By working with operational partners, investigators will identify opportunities and barriers to implementing access measures and metrics derived from their findings. This information will be key to setting policy related to VA’s evolution into a provider and payer of Veteran care while ensuring that Veterans receive high-quality care in both VA and non-VA settings. Results also will be useful to national and local VHA leaders as they grapple with how to best improve access with a limited budget.

Principal Investigator: Todd Wagner, PhD, is Director of HSR&D’s Health Economics Resource Center (HERC), and also is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Publications

Rose L, Aouad M, Graham L, Schoemaker L, and Wagner T. Association of expanded health care networks with utilization among Veterans Affairs enrollees. JAMA Network Open. October 1, 2021;4(10):e2131141.

View study abstract